One of the most difficult management issues in lupus nephritis (LN) is the optimal duration of maintenance immunosuppression after patients are in clinical remission. Most patients receive immunosuppression for years, based mainly on expert opinion. Prospective data are unavailable. Complicating this issue are data that patients in clinical remission can still have histologically active LN; however, the implications of this are unknown. To study this, the Lupus Flares and Histological Renal Activity at the end of Treatment study (ClinicalTrial.gov, NCT02313974) was designed to examine whether residual histologic activity predisposes to LN flares in class III and IV LN. Patients in complete clinical remission for at least 12 months who had received at least 36 months of immunosuppression were eligible. Patients consented to a second kidney biopsy, were tapered off maintenance immunosuppression and were then followed prospectively for LN flares over 24 months. Forty-four patients were enrolled, and 36 completed the study. LN flares occurred in 11 patients, and ten of these had residual histologic activity on the second biopsy. All patients with an NIH activity index over two flared. The activity index and duration of systemic lupus erythematosus at the second biopsy were independent predictors of flare. A predictive equation based on these variables discriminated between flare and no flare with a sensitivity of 100%, specificity of 88%, and a misclassification rate of 8.3%. Thus, a repeat kidney biopsy may be useful in managing maintenance immunosuppression in LN, and patients in histologic remission may be candidates for withdrawal of therapy.

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A 23-year-old woman presented with hematuria. Her blood pressure was normal, and she had no rash, joint pain, or other symptoms. Urinalysis was positive for proteinuria and hematuria, and urinary sediment analysis showed dysmorphic red blood cells (RBCs) and red cell casts, leading to a diagnosis of glomerulonephritis. She had proteinuria of 1.2 g/24 hours. Laboratory tests for systemic diseases were negative. Renal biopsy study revealed stage III immunoglobulin A (IgA) nephropathy. See related editorial, page 22 ■ GLOMERULAR HEMATURIA Glomerular hematuria may represent an immune-mediated injury to the glomerular capillary wall, but it can also be present in noninfl ammatory glomerulopathies. 1

Background Mesenchymal stem cells (MSCs) are known to possess significant immunosuppressive properties, and their use in refractory SLE is supported by promising safety and efficacy in autoimmune animal models and human trials. We conducted this phase I open-label study to test the hypothesis that a single infusion of human allogeneic umbilical cordderived MSCs (IND 16377) is safe when added to standardof-care therapy for active SLE. The primary safety outcome is frequency of Grade 3 or higher adverse events (AEs) by Week 24. The primary efficacy outcome is change in SLE disease activity between Baseline and Week 24 measured by SLEDAI score and prednisone dose.